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Commissioning must be an effective brake on demand

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Clinical commissioning has arrived, but it will take a while before it becomes clear whether it is creating order or chaos. Now may be an appropriate time to revisit the underlying principles to see how it is likely to pan out.

Commissioning is not a simple notion, but an inclusive concept that covers a number of different functions. At the ‘micro’ level, there is the direct procurement of individual services, a process that has been called contracting: the customer pays the supplier for a service on which they agree.

Let’s say the customer is a home-owner, who wants a new kitchen; he has a rough idea of what he wants (the ‘output specification’, if you like) but as he doesn’t know much about building kitchens, he will need to capitalize on the supplier’s expertise and trust him to do the job well. Success will be measured in terms of overall quality and satisfaction, timeliness, and costs, and if these aren’t met, the buyer may have to use the contract to hold the supplier to account, and gain redress for any failure.

In NHS terms, such micro-commissioning is based on GPs’ referral decisions: GPs know roughly what they want, and they have a knowledge of the local expertise; their role is to organize specific procedures with the appropriate experts, and then check that they been carried out to the agreed specification.

They have the advantage over the home-owner that their knowledge of specialist provision, whilst not encyclopedic, is detailed enough to let them make realistic assessments of quality and perception, timeliness, and costs.

At this level, one would not expect the home-owner or the GP to make decisions based on strategic impact or links to a European Directive; it would be for the specialist expert in each case to keep their customers apprised of any legal issues, and it would be the experts who would be held responsible for any non-compliance.

At the ‘macro’ level, the parallel relationship may be that between the town planners and a major home-builder; as with the individual kitchen, there needs to be agreement based on a mutual understanding of the outcome of the job, and any necessary markers of its progress.

Thus, the planners may want the new estate to be carbon neutral, to fit into the existing architectural ‘mood’, and to be completed within a certain time, to a specified quality, at an agreed cost; if they are sensible, they will leave it to the technical experts to decide the precise manner in which they respond to these specifications. Not only does that involve the builders in the decision-making and so keep them engaged and enthusiastic, it also maximizes the benefits of their expertise and promotes a degree of risk-sharing, that divides up the responsibility (legal, financial, perceptual) for the project, and ensures that both parties need to attain the same positive outcome to be satisfied.

Back in the NHS, this relationship mirrors that between strategic commissioners and the acute sector pretty well. Like the town planners, the strategic commissioners will need to incorporate national policies and regulations into their strategies. They will need enough knowledge to ensure that their providers are not pulling the wool over their eyes, without getting bogged down in the level of operational detail that boomerangs risks back to them whilst raising the transaction cost of the whole process.

At this level, the quantum being procured is much larger, and so its ‘contestability’ is much harder; a local authority, having agreed for a contractor to build them a whole new housing estate, would find it much more complex to withdraw from their contract than if they were contracting for a single kitchen. However, a competent authority should have levers to pull, should the builder not fulfill their side of the agreement.

And it is here that we come to the nub of whether or not commissioning in the NHS will succeed.

While developing and monitoring contracts (like any other performance management system) should be based on the carrots of success, it should be backed up by sanctions that are appropriate and viable.

Such levers should ultimately be based on the ability and feasibility of withdrawing the contract, something that itself depends on the availability of alternative provision and the consequences of such action (be they financial, legal, and perceptual, with the added complexity of how they affect the health of the population involved).

When the notion of commissioning first appeared the NHS in 1990 in the guise of the ‘purchaser/provider split’, its main purpose was to steer the acute sector away from fuelling ‘supply-led demand’ in health services and towards a new responsiveness to the needs of the population.

In fact, several iterations of change have not really had major impact on the acute sector, which still seems to be relatively unaffected by the current organizational changes, although it is facing some highly challenging financial pressures.

As long as it remains impractical to offer real challenge to the acute sector, commissioning will be largely irrelevant, offering no more than minor political irritation to the vast and politically-aware acute sector.

The three key challenges for the new commissioners may be summarised as follows:

- At the micro-level, the development of more widespread alternatives for GP referrals needs to be encouraged; merely shifting referrals between different hospitals won’t be enough, as the ensuing Brownian motion is unlikely to promote any real change, just random movement.

What is required is the threat of removing activity from the sector entirely, which will depend either on practices being allowed to develop viable alternatives themselves, or other providers (private or otherwise) being given access to such provision.

- At the macro-level, the systems being developed (whether through contracts or other less tangible ‘currencies’) must not be allowed to become ‘too big to fail’.Keeping the quantum of exchange small enough to allow real contestability is going to be key if commissioning is to become an effective management philosophy.

Thus for example, it is much easier to challenge the provision of a single service (physiotherapy, pathology, orthopaedic surgery) where real service delivery changes may be seen, than in trying to shut down an entire hospital, or even parachuting a new management team into a failing Trust, where direct patient care is unlikely to be affected (at least in the short term).

- And at the ‘meso’ level that spans micro and macro, it will be vital that the consequences of any actions be seen quickly and directly. If the GPs in a CCG want to repatriate a service out of the acute sector and into the community and it takes three years and a warehouse-full of bureaucracy to do it, then the GPs will simply give up trying. The links between input and effect need to be obvious and the accountability for both needs to be transparent and appropriate.

If commissioning becomes an ineffectual brake on demand, then we may as well abandon the whole concept now; however, if we manage these cultural changes, then the introduction of the new commissioning arrangements have the potential to be the ‘pivot point’ for changing the entire dynamic of the NHS.

Dr Jonathan Shapiro is an a former GP with wide experience in clinical, managerial, and academic roles. He works with policy makers, organisations and individuals to develop effective, sustainable systems with integrated clinical and managerial functions You can email Dr Shapiro on jsx@me.com.

Readers' comments (2)

  • The genie is out of the bottle. Holding back demand is like King Canute trying to hold back the tide. And since the NHS is free at the point of delivery, there is no brake. If I want a Mercedes rather than a Vauxhall the "brake" is the cost but if the cars were all free, I'd have a Ferrari thanks.

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  • Completely agree with the above. Yesterday I had to persuade a patient to consider fluoxetine 3x20mg, rather than 60mg tabs (cost diff £455/year). Patient was understanding but not too impressed he had to take 3 tablets now.

    "would you consider paying £455/year for the convenience?"
    "no, that's too expensive"
    "if it is too expensive for you, then please consider NHS is being funding this through your tax."
    "oh, ok, I see your point"

    Now this is an understanding patient who works. You could imagine what other answers I get in a different circumstance.

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